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<br />~ <br />~~HILLS <br /> <br />City of Arden Hills <br />1245 West Highway 96 <br />Arden Hiiis, Minnesota 55112 <br />Phone: 651.634.5120 <br />Fax: 651.634.5137 <br />www.ci.arden-hills.mn.us <br /> <br /> <br />License No. <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. Cerl. <br />Total Fee Paid <br /> <br />2007 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br /> <br />Information (allfields are required) <br /> <br />tnt.) <br />fl4l..e.~Y6 Ar6"" tk.:>1 - )273 vJ. (!.~.,u.1f. PH.J&4.lJlJ~ ~S'J/:;' <br />--'?().. Jt_I~_~ So-l e .s <br />TY\A I).l.. Y fJ ()A-I"n._th.~~_____ <br />J~!.~1---..l..f i' I - () b 7 :t <br /> <br />Business Name: <br /> <br />L. AO '1 <br /> <br />';;1.\ PPe' IL (J ltfTPTf; tt <br /> <br />At3I.()A <br /> <br />Property Address: <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />--- <br /> <br />Business Fax: <br /> <br />Email Address: <br /> <br />Website Address: <br /> <br />~ <br /> <br />- <br /> <br />Federal ID#: <br /> <br />___lJL:J'tQJ~ 9 Co <br /> <br />Premlse Permlt and Investigation Fee <br /> <br />$100.00 <br /> <br />'2006 Income and Loss Statement <br />'Projected 2007 ReceiptslPrizes <br />'Copy of Lease Agreement <br /> <br />,./" <br />,/ <br />./ <br /> <br />(All organizations permitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />net profits derived from gambling activities within the City to a special fund to be administered by the City Council for lawful <br />purposes. Payments to the fund shall be calculated for quarterly periods ending on the last days of March, June, September and <br />December. Quarterly installment payments shall be submitted together with verifiable supporting documentation no later than the <br />twentieth day ofthe month following the end of the qU<rr!erly period.) <br /> <br />Authorized Signature_~~ .~~~__c.i!li2.._. Date...'f:-[t!-::Yl.Z. <br /> <br />Received <br />MAY -1 Z007 <br /> <br />City of Arden Hills <br />